Nutrition Assessment in the Inpatient Setting Patient’s with Pressure Ulcers For HMC Wound Care Nurses

1. Nutrition Assessment in the Inpatient SettingPatient’s with Pressure UlcersFor HMC Wound Care Nurses Katie Farver RD, CNSD Harborview Medical Center Seattle, Washington kef@u.washington.edu 8-11-09

3. Components of Nutrition Assessment

4. Diet History Quality and quantity of food Intake prior to admit/during admit Quality and quantity of nutrition Support intake prior to admit/during admit

5. Medical History Sample conditions effecting intake Sample Drug-Nutrition Interaction Insulin Coumadin MAOI Inhibitors HAART INH • GI Disease • Chronic Alcoholism • Critical Illness • Stroke • Anorexia Nervosa • Dementia • Pancreatitis • Renal Disease

6. Weight History • Weight Loss over last 6 months evaluated: • <5% insignificant • 5-10% potentially significant • >10% significant • BMI = weight(kg)/height(m)² • <18.5 underweight • 18.5-24.9 normal, healthy • 24.9-29.9, overweight • >30 obese

7. Body Composition Measurements Underwater Weighing Skin Fold Measurements

8. Biochemical Assessment

9. Sources of Error • Biological Variation • Preanalytical variation • Analytical variation • Postanalytical variation

10. Synthesis rate Secretion rate Clearance rate Catabolic rate Distribution Other Factors Influencing Concentration

11. Synthesis rate • Substrate availability • Hepatic function • Metabolic response to injury • Corticosteroids • Inflammatory Response

12. Secretion and Clearance Rate • Cofactor availability • Hepatic Function • Renal Function

13. Distribution and Other • Metabolic response • Hydration • Drainage and fistula losses • Analytical Method • Patient position on blood draw

14. Biochemical Markers of Protein Status • Assessing Protein-Calorie Malnutrition • Albumin • Pre-Albumin

15. Serum Protein levels are not reliable during inflammation

16. Albumin • Half-life - 20 days • Under/over hydration, liver function • Function • Oncotic pressure, transport, nutritive reserve • Determinants of synthesis • Oncotic pressure, hormones, negative acute-phase reactant, nutrition support, aging, drugs

17. Transthyretin - TTY (Prealbumin) • Half-life - 1-2 days • Transports thyroid hormones and Vitamin A in Retinol Binding Protein Complex • Negative acute-phase reactant •  > 65% energy needs met, •  <50% energy needs met • Elevated in Renal Disease • Elevated with steroid therapy

18. C-Reactive Protein • Positive acute-phase protein • Reacts with Somatic C Polysaccharide of Strep. Pneumoniae • Half-life 5 hours • Changes with acute & chronic inflammation • Helps interpret Transthyretin and Albumin

19. How many of our patients are not experiencing acute stress?

20. Biochemical Markers of Micronutrient Status • Nutritional Anemias • B-12 • Iron • Copper • Vitamins • A • B Vitamins • Vitamin D • Minerals • Zinc • Antioxidants • Vitamin C • Vitamin E • Selenium

21. Lipid and Glycemic Status • Lipids • Total Cholesterol • HDL/LDLs • Homocysteine • Triglycerides • Glycemic Control • Blood Glucose • HgA1C

22. Physical AssessmentPhotos courtesy of Katy Wilkens, MS, RDNW Kidney Center, Seattle, WA

23. Wasted Clavicle

24. The Shoulder and Elbow • The shoulder • Normal: rounded or sloped • Abnormal: square, can see acromion process • The elbow well padded and not showing cartilage definition

25. The Arm • Bend arm and pinch at triceps. Only pinch the fat, not the muscle. • Normal: fingers don’t meet • Abnormal: fingers meet

26. Forearm • Forearm: often better site than upper arm for assessing fat • Upper arm fat disposition changes as women age

27. Wasting in the hands

28. The calf muscle • Grip the calf • Normal: muscle obvious, top of calf is larger than bottom • Abnormal: muscle reduction, “stick legs, ankles the same as upper leg

29. The Legs showing muscle wasting

30. Quadriceps and Knees

31. The Ankles • Good indicator of edema, but only in patients who walk • Check for sacral edema as well. • Overnourished patients can be harder to assess

32. The back side • In hospitalized patients, the back may not be easily accessible.

33. Vitamin C Deficiency Petechia Cork Screw Hair

34. Clinical Dietitians at HMC Nutrition Assessment is Complex • Putting the pieces together is challenging • Step-wise approach to assessment • Call 744-4612 anytime for consults (seen within 24 hours) • Call RD directly if urgent • ICU – assigned by team • Acute Care – assigned by floor

35. Where to find nutrition information in ORCA • Admit Nursing History • Weight trending • Dietitian and Dietetic Technician Notes • Enteral and TPN Flow Sheets • Discharge nutrition counseling